Higher-calorie refeeding a good bet for teens with anorexia

In the treatment of young people with anorexia nervosa (AN), starting refeeding at higher calories (HCR) is just as effective as doing it at lower calories (LCR), according to data from the STRONG* trial.

“We found that rates of clinical remission did not differ between HCR and LCR, which is the current standard of care. Importantly, [the former] was not associated with higher rates of medical readmission, number of readmissions, or an increase in the total number of hospital days after the initial admission,” said a team of US-based researchers.

The idea of starting low and going slow in the care of AN patients is based on concerns about refeeding syndrome, which is a name for a bundle of electrolyte disturbances and multiorgan dysfunction that can develop early in the refeeding course of malnourished patients. This approach is associated with slow weight gain and long hospitalization, as the researchers pointed out. [Int J Eat Disord 2012;45:439-442; J Adolesc Health 2012;50:24-29; bit.ly/3rfLvsq]

HCR, in comparison, has been reported to cut the time it takes to gain weight and the length of hospital stay without increasing the risk of refeeding syndrome. In STRONG, the researchers examined whether other clinical outcomes would differ between HCR and LCR. They enrolled 120 patients with AN or atypical anorexia nervosa (AAN) aged 12 to 24 years who were admitted for medical instability and whose weight, despite significant loss, remained in the normal or above normal range. [J Adolesc Health 2013;53:573-578; J Adolesc Health 2013;53:579-584]

The patients were randomized to undergo HCR (2,000 kcals per day, increasing by 200 kcals per day) or LCR (1,400 kcals per day, increasing by 200 kcals every other day) within 24 hours of admission and followed-up at 10 days and 1, 3, 6, and, 12 months after discharge.

A total of 111 patients (mean age 16.4 years, 91 percent female, 65 percent non-Hispanic White) were included in modified intent-to-treat analyses, 60 in the HCR arm and 51 in the LCR arm. Clinical remission at 12 months postdischarge (weight restoration ≥95 percent median body mass index [BMI] plus psychological recovery) changed over time in both treatment arms, with no significant differences (p=0.42). [Pediatrics 2021;doi:10.1542/peds.2020-037135]

Results for the secondary endpoints confirmed the researchers’ hypothesis that HCR and LCR would not differ in terms of medical rehospitalization rates within 1 year postdischarge (32.8 percent vs 35.4 percent, respectively; p=0.84), number of rehospitalizations (mean, 2.4 vs 2.0; p=0.52), and total number of days rehospitalized (mean, 6.0 vs 5.1 days; p=0.81).

For too long, the researchers said, consensus-based recommendations for LCR have endured for decades due to lack of well-designed trials to assess efficacy and inform clinical guidelines. “With the findings reported here, we provide the evidence to inform updated treatment guidelines for adolescents and young adults with restrictive eating disorders who are >60 percent median BMI.”

In an accompanying editorial, Dr Mark Norris of the University of Ottawa and Children’s Hospital of Eastern Ontario, Ontario, Canada, and Dr Jennifer Couturier of McMaster University, Hamilton, Ontario, Canada, said that the data from STRONG are meaningful both “statistically” and “economically.” This is in light of recent estimates that direct overall health systems costs for individuals with eating disorders in the US alone surpassed 4.5 billion dollars in 2018–2019. [Pediatrics 2021;doi:10.1542/peds.2020-043737; bit.ly/31bWDfk]

However, the experts pointed out the fact that the trial excluded patients with a median BMI <60 percent, which means there is no evidence of the safety of HCR for very low-weight patients.

“Further studies in which researchers explore how such protocols are tolerated by very low-weight patients are required to better understand the utility of this treatment approach across varying patient populations,” Norris and Couturier said.

*The Study of Refeeding to Optimize Inpatient Gains